Document 6440717

Form W-4 (2014)
The exceptions do not apply to supplemental wages
greater than $1,000,000.
Purpose. Complete Form W-4 so that your employer
can withhold the correct federal income tax from your
pay. Consider comp!ettng a new Form W-4 each year
and when your personal or financial situation changes.
Exemption from withholding. If you are exempt.
complete only lines 1, 2, 3, 4, and 7 and sign the form
to validate it. Your exemption for 2014 expires
February 17, 2015. See Pub. 505, Tax Withholding
and Estimated Tax.
Basic instructions. If you are not exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Note. If another person can c!aim you as a dependent
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
on his or her tax return, you cannot claim exemption
from withholding if your income exceeds $1,000 and
Includes more than $350 of unearned income (for
example, interest and dividends).
Exceptions. An employee may be able to claim
exemption from withholding even if the employee is a
dependent, if the employee:
Head of household. Generally, you can clafm head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other quaHfy!ng individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Ffllng Information, for Information.
• Is age 65 or o!der,
Tax credits. You can take projected tax credits into account
in figuring your allowable number of withholding allowances.
Credits for child or dependent care expenses and the child
tax credit may be claimed using the Personal Allowances
Worksheet below. See Pub. 505 for information on
converting your other credits Into withholding allowances.
• ls blind, or
• Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax return.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES, Estimated Tex for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
iincome, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Allens, before
completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2014. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. Information about any Mure
developments affecting Form W-4 (such as leglslation
enacted after we release It) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
A
Enter "1" for yourself if no one else can claim you as a dependent .
A
•You are single and have only one job; or
• You are married, have only one job, and your spouse does not work; or
}
B
Enter "1" if:
c
•Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less.
Enter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a working spouse or more
than one job. (Entering "-0-" may help you avoid having too little tax withheld.) .
D
E
F
{
B
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return .
c
D
E
F
Enter "1" if you will file as head of household on your tax return {see conditions under Head of household above)
Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G
Child Tax Credit (Including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $65,000 ($95,000 if married), enter "2" for each eligible child; then less "1" if you
have three to six eligible children or less "2" If you have seven or more eligible children.
• If your tataJ income will be between $65.000 and $84.000 ($95.000 and $119.000 if rmrried), enter "1" for each eligible cnld .
G
H
Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) •
H
For accuracy,
complete all
worksheets
that apply.
I
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $50,000 ($20,000 If married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to
avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
-------·-·-·····-----------------· Separate here and give Form W-4 to your employer. Keep the top part for your records. --------------------·-·----------·
Fo•m
W-4
Department of the Treasury
Internal Revenue SetVice
•
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
Whether you are entiUed to claim a certain number of allowances or exemption from wtthholdlng is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
~@14
Your first name and middle initial
Last name
Home address (number and street or rural route)
2
3
0
Single
0
Married
D
Your social security number
Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the "Single" box.
City or town, state, and
I code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. •
5
6
Total number of allowances you are claiming {from line H above or from the applicable worksheet on page 2)
Additional amount, if any, you want withheld from each paycheck
7
I claim exemption from withholding for 2014, and I certify that I meet both of the following conditions for exemption.
D
•Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liabri_lit....,_._ _ _ __
If you meet both conditions, write "Exempt" here .
. 11o> 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee's signature
(This form Is not valid unless you sign it.) ""
8
Employer's name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Date•
9 Office code (optionaij
Cat. No. 102200
10
Employer identification number (EIN)
Form W~4 (2014)
.....
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.
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,•
Form WH-4
State Fonn 48845
""(R2/8-08)
State of Indiana
Employee's Withholding Exemption and County Status Certificate
This form is for the employer's records. Do not send this form to the Department of Revenue.
The completed form should be returned to your employer.
Full N a m e - - - - - - - - - - - - - - - - - - - - - - - Home Address _ _ _ _ _ _ _ _ _ _ _ _ _ __
Social Security Number or ITIN - - - - - - - - - - - -
City _ _ _ _ _ _ __
State___
Zip C o d e - - - - - - - - -
Indiana County of Residence as of January 1: - - - - - - - - - - - - - - - - - -
(See instructions)
Indiana County of Principal Employment as of January 1: - - - - - - - - - - - - - -
(See instructions)
How to Claim Your Withholding Exemptions
1. You are entitled to one exemption. If you wish to claim the exemption, enter "1"
Nonresident aliens must skip lines 2 through 6. See instructions
2. If you are married and your spouse does not claim his/her exemption, you may claim it, enter
u1~
3. You are allowed one (1) exemption for each dependent. Enter number claimed .............................................................................. .
4. Additional exemptions are allowed if: (a) you and/or your spouse are over the age of 65 and/or
(b) if you and/or your spouse are legally blind.
Check box( es) for additional exemptions: You are 65 or older D or blind D Spouse is 65 or older
Enter the total number of boxes checked ................................................................................ .
D or blind D
5. Add lines 1, 2, 3, and 4. Enter the total here
6. You are entitled to claim an additional exemption for each qualifying dependent (see instructions) ....................... .
...............
~~==~
~
~--~
7. Enter the amount of additional state withholding (if any) you want withheld each pay period
$ _ _ __
8. Enter the amount of additional county withholding (if any) you want withheld each pay period .....................................................
$ _ _ _ __
I hereby declare that to the best of my knowledge the above statements are true.
Signature:-----------------------------
Date: _ _ _ _ _ _ _ _ _ _ __
Indiana New Hire Reporting Center
Po Box 55097
Indianapolis, IN 46205
IN DIANA
new hire reporting center
EMPLOYER INFORMATION
DDDDDDDDDE
AS UI#)
EMPLOYER NAME
DDDDDDDDDDDDDDDDDDDDDDDD
DDDDDDDDDDDDDDDDDDDDDDDD
DDDDDDDDDDDDDDDDDDDDDDDD
DD DDDDD-DDDD
EMPLOYER ADDRESS (INCOME WITHHOLDING ADDRESS)
CITY
STATE
ZIP
EMPLOYER CONTACT INFORMATION
LAST
FIRST
DDDDDDDDDDD DDDDDDDDDDD
DDD-DDD-DDDD DDD-DDD-DDDD
DDDDDDDDDDDDDDDDDDDDDDDD
PHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
EMPLOYEE INFORMATION
SOCIAL SECURITY NUMBER
IS HEALTH INSURANCE AVAILABLE TO
ODD-DD-DODD
D D
DDDDDDDDDDDDDDDDDDDDDD D
DDDDDDDDDDDDDDDDDDDDDDDD
DDDDDDDDDDDDDDDDDDDDDDDD
DDDDDDDDDDD DD DDDDD-DDDD
DD!OD!ODDD
DD!OD!ODDD
EMPLOYEE? (OPTIONAL)
y
N
FIRST NAME
MI
LAST NAME
ADDRESS
CITY
STA TE
DATE OF BIRTH(OPTIONAL)
START DATE
mm
dd
ZIP
yyyy
Phone:
(317) 612-3028
Toll Free: (866) 879-0198
www.in-newhire.com
mm
dd
yyyy
Fax: (317) 612-3036
Toll Free: (800) 408-1388
www.IN.gov
Employment Eligibility Verification
USCIS
Form 1-9
Department of Homeland Security
OMB No. 1615-0047
Expires 03/31/2016
U.S. Citizenship and Immigration Services
~START HERE. Read Instructions carefully before completlng this fonn. The Instructions must be available during completion of this fonn.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future
expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attes~tl\S'""'Q::o/i/!~Y'?es,miI~l cOn\pJete and sign SiflJtion t~f~.1-9 np tater
than the first day of employment, but not before. a()(!eptil;Jg ajob·off<I')
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
Date of Birth (mmlddlyyyy)
.
U.S. Social Security Number
D-D-1
·
Middle Initial Other Names Used (if any)
City or Town
Apt. Number
I
,
State
E-mail Address
Zip Code
Telephone Number
I
I am aware that federal law provides for Imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this fonn.
I attest, under penalty of perjury, that I am (check one of the following):
0
0
0
0
A citizen of the United States
A noncitizen national of the United States (See instructions)
A lawful permanent resident (Alien Registration Number/USCIS Number): - - - - - - - - - - - An alien authorized to work until (expiration date, it applicable, mm/dd/yyyy) - - - - - - - . Some aliens may write "NIA" in this field.
(See instructions)
For aliens authorized to worl<, provide your Alien Registration Number/USC/S Number OR Form 1-94 Admission Number:
1. Alien Registration Number/USCIS Number: _ _ _ _ _ _ _ _ _ __
3-0 Barcode
OR
Do Not Write In This Space
2. Form 1-94 Admission N u m b e r : - - - - - - - - - - - - - - - -
If you obtained your admission number from CBP in connection with your arrival in the United
States, include the following:
Foreign Passport N u m b e r : - - - - - - - - - - - - - - - - - - - - - Country of Issuance: - - - - - - - - - - - - - - - - - - - - - - - Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)
ISignature of Employee:
IDate (mmlddlyyyy):
Preparer.and/or Translator Certlflcat1011 (To b6: comptilted/a'tiit Sigtied if Section 1 is prapart!id by iI•1Jefson <ttfrfrthiln t111i
employee.)
·
·
·
·. ~: '· · ''.'':'. ·.··
, . . ::~.:.'
·
· ·
·
·
··. ····
I attest, under penalty of perjury, that I have assisted In the completion of this fonn and that to the best of my knowledge the
infonnation is true and correct
I
Signature of Preparer or Translator:
Last Name (Family Name)
Address (Street Number and Name)
Form 1-9 03/08/13 N
Date (mmlddlyyyy):
First Name (Given Name)
ICity or Town
I State
I
Zip Code
Page 7 of9
Section 2. EmployerorAuthorized Representatlve.,Re~iewand VerlflC'
(Employers or their authorized repf!lS6ntaUve must complete end sign·~ '?iNlt!Jln J.business d~i/.:ih:the omp/oyeB'.s fffst.day of omplOyment. You
must physically examine one dOcument from List A OR examirle1i1Jldroblnatkm o(.Ori6'CfPCi,msnt.from Llst.B ana,ohe cloCilinen(from Lki/C as /Isled on
the "Lists of Acceptable Documents• on the next pege of this /Orrri. l'oi'~·dOcUmenl yoiinivff!w, recom the frilloW;ng lnfQRl7"1fim: lfOCl/ment titte,
issuing authority, document (lumber, and l!JXpiration date,· if ah,¥,!
,
, , ,
Employee Last Name, First Name and Middle Initial from Section 1:
List A
OR
AND
ListB
ListC
Identity and Employment Authorization
Document Title:
Document Title:
Document Title:
Issuing Authority:
Issuing Authority:
Issuing Authority:
Document Number:
Document Number:
Document Number:
Expiration Date (if any)(mmlddlyyyy):
Employment Authorization
Identity
;. ' Expiration Date (if any)(mmlddlyyyy):
Expiration Date (if any)(mmldd/yyyy):
~
Document Title:
~
Issuing Authority:
Document Number:
Expiration Date (if any)(mmlddlyyyy):
3-D Barcode
Do Not Write In This Space
Document Title:
Issuing Authority:
Document Number:
'
Expiration Date (if any)(mmlddlyyyy):
Certification
I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the
above~isted document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mmlddlyyyy)·
Signature of Employer or Authorized Representative
Last Name (Family Name)
(See instructions for exemptions,)
I
Date (mmldd/yyyy)
First Name (Given Name)
I
Title of Employer or Authorized Representative
IEmploye~s Business or Organization Name
I
IState
Employe~s Business or Organization Address (Street Number and Name) City or Town
IZip Code
Section 3,Reverificatlon.:and Rehire!> (To i/e iibmp/et9ciand'ij/g'ii9c(~Y.e.mploy6f.()(autlibfiZedl!1/ir(JllllntatlW.f
A. New Name (if applicable) Last Name (Family Name) First Name (Given Name)
I
Middle Initial B. Date of Rehire (if applicable) (mmlddlyyyy):
C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee
presented that establishes current employment authorization in the space provided below.
Document TiUe:
Document Number:
IExpiration Date (ff any)(mmlddlyyyy):
I attest, under penalty of perjury, that to the best of my knowledge, this employee Is authorized to work In the United States, and If
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual,
Signature of Employer or Authorized Representative:
Form 1-9 03/08/13 N
Date (mmlddlyyyy):
Print Name of Employer or Authorized Representative:
Page 8 of9
.
.
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LISTA
LISTB
Documents that Establish
Both Identity and
Employment Authorization
1. U.S. Passport or U.S. Passport Card
AND
. 1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
Registration Receipt Card (Fomn 1-551)
photograph or information such as
name, date of birth, gender, height, eye
color, and address
3. Foreign passport that contains a
temporary 1-551 stamp or temporary
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
4. Employment Authorization Document
that contains a photograph (Fomn
1-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
a. Foreign passport; and
b. Fomn 1-94 or Fomn l-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
6. Passport from the Federated States of
Micronesia (FSM) or the Republic of
the Marshall Islands (RMI) with Form
1-94 or Form l-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
Documents that Establish
Employment Authorization
Documents that Establish
Identity
2. Permanent Resident Card or Alien
1-551 printed notation on a machinereadable immigrant visa
LISTC
gender, height, eye color, and address
3. School ID card with a photograph
4. Voter's registration card
5. U.S. Military card or draft record
6. Military dependent's ID card
7.
U.S. Coast Guard Merchant Mariner
Card
1. A Social Security Account Number
card, unless the card includes one of
the following restrictions:
(1) NOT VALID FOR EMPLOYMENT
(2) VALID FOR \/\ORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR \/\ORK ONLY WITH
DHS AUTHORIZATION
2. Certification of Birth Abroad issued
by the Department of State (Fomn
FS-545)
3. Certification of Report of Birth
issued by the Department of State
(Form DS-1350)
4. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
8. Native American tribal document
6. Native American tribal document
9. Driver's license issued by a Canadian
6. U.S. Citizen ID Card (Fomn 1-197)
government authority
7. Identification Card for Use of
For persons under age 18 who are
unable to present a document
listed above;
Resident Citizen in the United
States (Fomn 1-179)
8. Employment authorization
10. School record or report card
11. Clinic, doctor, or hospital record
document issued by the
Department of Homeland Security
12. Day-care or nursery school record
the United States and the FSM or RMI
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-27 4).
Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review
and Verification," for more information about acceptable receipts.
Fonn 1-9 03/08/13 N
Page 9 of9